Key indicators contributing to prolonged emergency department stays in Saudi Arabia: a modified Delphi study

Key indicators contributing to prolonged emergency department stays in Saudi Arabia: a modified Delphi study

Emergency department, Length of stay, Prolonged LoS, Indicators, Saudi Arabia

Background A prolonged length of stay (LoS) in emergency departments (EDs) is a growing issue that affects patient
prognosis, resource allocation, and operational efficiency. In Saudi Arabia, an ED stay exceeding 8 h is considered
prolonged; however, few studies have identified the key elements contributing to this issue. This study aimed to
determine and rank indicators associated with prolonged LoS in EDs based on the consensus of emergency medical
practitioners in Riyadh, Saudi Arabia.
Methods A two-round modified Delphi study was conducted from September 2024 to January 2025. Purposeful
sampling included emergency physicians and nurses (129 in Round 1 and 137 in Round 2). Participants evaluated
34 potential indicators of prolonged ED stays using a Likert-scale questionnaire. Consensus was defined a priori, and
the top 10 indicators were reassessed in Round 2. Statistical analysis using SPSS included medians and interquartile
ranges (IQR), with significance set at p<0.05.
Results A total of 129 and 137 participants completed Rounds 1 and 2, respectively. The most important indicator
identified was the percentage of the ED occupied by inpatients. Other highly ranked indicators included the total ED
patient count, average time in the ED for admitted patients, and the number of boarding patients. These indicators
consistently showed high consensus, with a median (IQR) of 5 (1). Female ED workers rated inpatient occupancy,
time between decision to disposition, and boarding patients as higher contributors to prolonged LoS (p<0.03). ED
nurses rated the average time in the ED for admitted patients, consult-to-disposition time, and physician availability as
stronger indicators of prolonged LoS in the ED (p<0.014).
Conclusion Inpatient boarding, reflected by the percentage of the ED occupied by inpatients and the number of
boarding patients, was the primary factor contributing to prolonged LoS in Saudi EDs. These findings emphasize that
prolonged LoS in the ED is a hospital-wide challenge requiring coordinated action from healthcare administrators
and policymakers to expedite inpatient discharges and optimize ED processes. Enhancing national programs such as
Ada’a by incorporating these indicators into performance metrics may improve ED efficiency and patient care in Saudi
Arabia.

Lujain Aljohani1*, Nuwayyir Abdullah Alqasimi1

, Waleed Alharbi2

, Mohammed Alshalhoub3

, Abdulrahman Alrajhi3
,

Nasser Alkahtani3

, Reem Alshehri3

, Ahmed Hussein Alkohlani2

and Majid Alsalamah3,4

https://doi.org/10.1186/s12873-025-01438-y

2026

Peri Irawan

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